Published 2/1/2009

Second Look

If you missed these Headline News Now items the first time around, AAOS Now gives you a second chance to review them. Headline News Now—the AAOS thrice-weekly, online update of news of interest to orthopaedic surgeons—brings you the latest on clinical, socioeconomic, and political issues, as well as important announcements from AAOS. Links to additional information are available online at www.aaosnow.org

New classification system proposed for spinal deformity
A research team has proposed a new classification system for spinal deformity that defines spinal abnormalities in all patients, regardless of age. The researchers conducted a literature review to identify studies that evaluated neutral upright spinal alignment (NUSA) from the occiput to the pelvis in asymptomatic individuals. They selected 17 angles and displacements to depict neutral upright coronal and axial spinal alignment, and 21 angles and displacements to depict neutral upright sagittal spinal alignment. Researchers used the data to calculate pooled estimates of the mean and variance for the angles and displacements, and developed a new classification of spinal deformity based on age-dependent NUSA; spinal abnormality; deformity curve location, pattern, magnitude, and flexibility; and global spinal alignment. The system appeared in the September 2008 issue of the journal Neurosurgery.

Study examines link between alcoholism and osteoporosis among younger patients
Younger alcoholic patients without other diseases may be at increased risk of osteoporosis, according to the results of a study published online in the journal Alcoholism: Clinical and Experimental Research. The cross-sectional study covered 57 noncirrhotic alcoholic patients (37 male, 20 female) aged 27 to 50 years. None of the patients was suffering from comorbid somatic diseases or taking medication known to have an influence on bone mineral density (BMD). The research team found that BMD was significantly reduced in the lumbar region and the proximal femur in male patients. Nine male patients and one female patient had low BMD. Overall, 75.7 percent of the men and 90 percent of the women had vitamin D insufficiency or deficiency. Alcohol-related factors and smoking were not associated with a significant effect on BMD. All of the women in the study group showed elevated estradiol levels, which the researchers propose may have served as a protective factor.

Popular diabetes drug may increase fracture risk in diabetic women
A study published in the Jan. 6 issue of the Canadian Medical Association Journal finds that long-term use of thiazolidinedione, an oral diabetes treatment, may increase risk of fracture among women with type 2 diabetes. The authors conducted a meta-analysis of 10 randomized controlled trials (13,715 participants) of patients with type 2 diabetes and two observational studies (31,679 participants) that described the risk of fractures or changes in bone density with thiazolidinediones.

Rosiglitazone and pioglitazone were found to be associated with an increased risk of fractures overall in the 10 randomized controlled trials. Five randomized controlled trials showed a significantly increased risk of fractures among women but not among men. The two observational studies demonstrated an increased risk of fractures associated with rosiglitazone and pioglitazone. In two randomized controlled trials, BMD in women exposed to thiazolidinediones was significantly reduced at the lumbar spine.

Postthrombotic syndrome common in DVT patients
As many as 43 percent of patients with deep vein thrombosis (DVT) may develop postthrombotic syndrome, according to the results of a Canadian study published in the journal Annals of Internal Medicine. In the prospective, multicenter cohort study of 387 patients receiving an objective diagnosis of acute symptomatic DVT between 2001 and 2004, the authors found that about 30 percent of patients had mild, 10 percent had moderate, and 3 percent had severe postthrombotic syndrome at all study intervals (1, 4, 8, 12, and 24 months after enrollment). They also found a greater postthrombotic severity category at the 1-month visit that correlated to higher mean postthrombotic scores throughout the 24 months of follow-up. Additional predictors of higher scores were venous thrombosis of the common femoral or iliac vein, higher body mass, previous ipsilateral venous thrombosis, older age, and female sex.

Adjusting warfarin dosing to optimize anticoagulation
A study published in the January issue of the Journal of Thrombosis and Haemostasis suggests that anticoagulation control may be improved by changing warfarin dose only when the International Normalized Ratio (INR) is 1.7 or lower, or 3.3 or higher. The authors conducted an observational study of 3,961 patients receiving warfarin from 94 community-based clinics over a mean time of 15.2 months. For each patient, they computed an observed minus expected (O–E) score, comparing the number of dose changes predicted by the model to the number of changes observed, and examined the ability of O–E scores to predict time in therapeutic INR range (TTR). The best INR control was achieved among patients who deviated the least from the predicted number of dose changes, while patients with greater deviations had lower TTR. On average, clinicians in the study changed the dose when the INR was 1.8 or lower/3.2 or higher; optimal management would have been to change the dose when the INR was 1.7 or lower/3.3 or higher.

Healthcare providers “cost shift” more than $88 billion per year
Low Medicare and Medicaid reimbursements lead to higher health insurance costs as healthcare providers shift shortfalls to consumers and private health insurers, according to a report commissioned by America’s Health Insurance Plans, the American Hospital Association, the Blue Cross Blue Shield Association, and Premera Blue Cross. The researchers found that in 2006, the hospital cost shift was $34.8 billion for Medicare and $16.2 billion for Medicaid. In 2007, the physician cost shift was $14.1 billion for Medicare and $23.7 billion for Medicaid. Taken together, the estimated annual cost shift is $88.8 billion. The authors determine that cost shifting adds an estimated 10.6 percent to the aver­age premium for a family of four.

IOM report examines HHS challenges
A study published by the U.S. Institute of Medicine (IOM) identifies factors that affect the ability of the Department of Health and Human Services (HHS) to address its responsibilities. Factors include divergence in the missions and goals of the department’s agencies, limited flexibility in spending, impending workforce shortages, difficulty in retaining skilled professionals, and challenges in effectively partnering with the private sector. The authors recommend against a large-scale reorganization of HHS in favor of more effective alignment of departmental operations, along with improved processes for goal setting, decision making, management, and accountability.